Real-world evidence of superiority of endovascular repair in treating ruptured abdominal aortic aneurysm.

Gupta, Akshay Kumar Dakour Aridi, Hanaa Locham, Satinderjit Nejim, Besma Veith, Frank J Malas, Mahmoud B

REVIEW


09 June 2018

There is a lot of data already to show that endovascular aneurysm repair is safer than open surgery techniques so this study does not add much new knowledge. However, it is very relevant for advancing the drive to get clinicians to do less invasive procedures for safety reasons.


RELEVANCE 2
INNOVATIVENESS 4
APPLICABILITY 4
OVERALL 3

PAPER DETAILS


TITLE

Real-world evidence of superiority of endovascular repair in treating ruptured abdominal aortic aneurysm.

ABSTRACT

OBJECTIVE
The majority of previous studies, including randomized controlled trials, have failed to provide sufficient evidence of superiority of endovascular aneurysm repair (EVAR) over open aortic repair (OAR) of ruptured abdominal aortic aneurysm (rAAA) while comparing mortality and complications. This is in part due to small study size, patient selection bias, scarce adjustment for essential variables, single insurance type, or selection of only older patients. This study aimed to provide real-world, contemporary, comprehensive, and robust evidence on mortality of EVAR vs OAR of rAAA.

METHODS
A retrospective observational cohort study was performed of rAAA patients registered in the Premier Healthcare Database between July 2009 and March 2015. A multivariate logistic regression model was operated to estimate the association between procedure types (OAR vs EVAR) and in-hospital mortality. The final model was adjusted for demographics (age, sex, race, marital status, and geographic region), hospital characteristics (urban or rural, teaching or not), and potential confounders (hypertension, diabetes, hypercholesterolemia, obesity, ischemic heart disease, chronic kidney disease, symptoms of critical limb ischemia, chronic obstructive pulmonary disease, smoking, and alcoholism). Furthermore, coarsened exact matching was applied to substantiate the result in the matched cohort.

RESULTS
There were a total of 3164 patients with rAAA (1550 [49.0%] OAR and 1614 [51.0%] EVAR). Mortality was 23.79% in the EVAR group compared with 36.26% in the OAR group (P < .001). The adjusted odds ratios of mortality (1.91; 95% confidence interval [CI], 1.62-2.25; P < .001), cardiac complication (1.54; 95% CI, 1.22-1.96; P < .001), pulmonary failure (1.90; 95% CI, 1.60-2.24; P < .001), renal failure (1.90; 95% CI, 1.61-2.23; P < .001), and bowel ischemia (2.40; 95% CI, 1.70-3.35; P < .001) were significantly higher after OAR compared with EVAR. We further applied coarsened exact matching, which followed the same pattern of mortality (odds ratio, 1.68; 95% CI 1.41-1.99; P < .001) and all major complications.

CONCLUSIONS
Although the choice of repair of rAAA is highly dependent on the experience of the operating team and the anatomic suitability of the patient, this contemporary analysis of a large cohort of rAAA showed significantly higher adjusted risk of mortality in OAR compared with EVAR and substantially higher complications.



AUTHOR(S)

Gupta, Akshay Kumar Dakour Aridi, Hanaa Locham, Satinderjit Nejim, Besma Veith, Frank J Malas, Mahmoud B

JOURNAL

Journal of vascular surgery

PLACE

United States